Professional Documents
Culture Documents
6098
6098
1.
INTRODUCTION
2.
General principles:
Comprehensive pain assessment prior to treatment
Understanding the concept of total pain
Reassessment and adjustment of treatment when indicated
Inter-professional collaboration in multidisciplinary teams
Participation of patients and their family members/carers
Comprehensive assessment of pain is the first step to achieve
successful cancer pain management for all levels of healthcare
providers.27, 28, level III
In patients with cancer pain, it is important to understand the concept
of total pain as introduced by Dame Cicely Saunders.29, level III In total
pain, patients pain experience may have physical, psychological,
social, emotional, and spiritual components. Effective pain relief can
only be achieved if complete and thorough assessments of these
components are obtained.
Cancer pain relief is also achieved by understanding the framework
of a human person (a unique personal history and inheritance with a
complex personal environment) and the use of a four-pronged approach
to pain relief including:30, level III
i. assessment and reduction of noxious stimulus using measures
such as anticancer therapy (chemotherapy, radiotherapy, surgical
procedures), adjuvant drugs and nerve-blocking techniques
ii. increasing patients pain threshold by relieving pathological
anxiety, depression, or existential anguish
iii. use of opioid drugs and other analgesics
iv. recognition and treatment of neuropathic pain
The concept of team work and interdisciplinary management of cancer
pain is essential in palliative care. Teams consisting of physicians,
pharmacists and nurses manage cancer pain better than individual
providers.28, level III Careful monitoring of pain coupled with adjustment
of treatment strategy when indicated and continued assessment of
treatment effectiveness are components of effective cancer pain
management.31, level III
High intensity inter-professional collaboration in managing cancer pain
has shown:32, level III
Improvement in mean patient satisfaction (p<0.001)
Less uncertainty and concerns among patients (p=0.047)
Adequacy in pain management (p=0.016)
3
Patients and their families are units of care and issues affecting
caregivers can also affect patients care.33, level III Involvement of patients
and their family carers in the management of cancer pain reduces
barriers to analgesic use (p<0.0001) and decreases the worst pain score
(p<0.05).34, level I To further enhance the effectiveness of cancer pain
management, adherence to guidelines for cancer pain management
has shown to improve pain treatment efficacy as compared to standard
care (p<0.02).35, level I
3.
Somatic Pain
Visceral pain
Site single/multiple
Quality sharp/dull/throbbing/colicky, etc.
Intensity pain score
Timing persistent/episodic/on movement/spontaneous
Radiation of pain
Aggravating and relieving factors
Associated symptom numbness / abnormal sensation /
hyperalgesia / allodynia, etc.
Cancer history
Site(s) primary/metastatic
Treatment(s) surgery/chemotherapy/radiotherapy
Medication
Analgesia
Side effects
Concurrent medications including traditional/alternative
medications
Treatment response/adherence
Co-morbidities
Renal/liver disease
Cardiac/respiratory disease
Cognitive impairment
Other pain conditions acute/chronic
Previous alcohol or drug abuse
Psychosocial
used include EORTC QLQ-C30 Pain Scale, SF-36 Bodily Pain Scale
and the Short Form McGill Pain Questionnaire (SF-MPQ). In Malaysia,
multidimensional measures are used mainly in research as they are
less practical for day to day clinical use.
A systematic review recommended that the ideal pain assessment
tool for patients in palliative care should be precise (high validity
and reliability), short and flexible for use in different populations and
situations.49, level II-1
Although self-report of pain is the gold standard, this may not be the
case in cognitively impaired adults, especially those with moderate to
severe impairment. In a review which evaluated the tools based on
behavioural indicators for pain assessment in nonverbal older adults
with dementia, Herr K et. al. concluded that there is no standardised
tool that can be recommended.50, level III However, the MOH Pain as the
5th Vital Sign guidelines recommend the use of the Face Legs Activity
Cry Consolability (FLACC) scale for cognitively impaired adults.37 - 39, level III
Health care providers looking after cognitively impaired adults should
search for potential sources of pain and use behavioural indicators to
assess pain. Obvious pain behaviours include grimacing and rubbing
the painful part but less obvious behaviours like irritability, aggression or
changes in activity pattern and appetite may also indicate pain. Surrogate
reporting of pain by carers/family members has also been shown to be
accurate (p=0.014)51, level III and in cases where pain is suspected in a
demented person, a trial of analgesics may be warranted.52, level III
3.2.5 Psychosocial Assessment
The meaning of pain for patients with cancer may be different compared
to those with pain due to non-malignant conditions. Physical pain
is perhaps one of the most feared consequences for patients with
cancer.53, level III In general, the experience of chronic pain may mean
loss of control, power and authority, dependence on analgesics and
repeated treatments as well as socio-economic threats. In addition,
some cancer patients may see pain as a sign of disease progression
leading to loss of hope for cure or as a punishment for previous wrong
doings. Hence pain has profound effects on mood, anxiety and other
psychological symptoms.54 - 55, level III
10
patients.27; 61, level III The patient therefore is the most reliable assessor
of his/her pain provided he/she is competent and able to communicate
appropriately.27
Assessment of cancer pain by patients and nurses differed significantly
in most intense pain (p=0.006) and acceptable pain (p=0.05).61, level III
Nurses tended to underestimate pain when they had poor knowledge
of pain medication in general (p=0.046) and morphine in particular
(p=0.043). In addition, specialised nurses with advanced education and
knowledge assessed patients pain more accurately than nurses who
did not have this additional training (p<0.05).
A study has also shown that discrepancy between patient and physician
in judging severity of patients pain was predictive of inadequate pain
management (OR=2.3).62, level III The greater the discrepancy, the more
likely pain management was inadequate. Patients with less adequate
analgesia reported less pain relief (p<0.001) and greater pain-related
impairment of function (p=0.02).
Patients and their families reported parallel perceptions of the
patients cancer pain with positive correlation in patients pain (r=0.67,
p=0.0001) and performance status (r=0.57, p=0.0001) although family
members consistently reported higher scores.63, level III Family members
assessments of pain are significantly related to appropriate knowledge
and attitudes on cancer pain (R2=0.27).
Recommendation
Accurate and comprehensive assessment should be performed prior
to treatment in all patients with cancer pain. (Grade C)
Unidimensional pain assessment tools such as the NRS, VAS and
VRS should be used regularly in the day to day assessment of
patients with cancer pain. (Grade B)
Psychosocial assessment should be carried out in all patients with
cancer pain. (Grade B)
Patients self-report provides the most reliable assessment of pain.
(Grade C)
11
4.
PHARMACOLOGICAL TREATMENT
12
14
Morphine
15
b.
Fentanyl
Oxycodone
Oxycodone is an alternative strong opioid and available in immediaterelease (IR) and controlled-release (CR) oral formulations. Both CR &
IR oxycodone are as effective as oral morphine.81, level III IR oxycodone
has a Tmax of 1 hour and half-life of 3.5 - 5.7 hours.87, level III The CR
oxycodone is absorbed in a bi-exponential fashion with a rapid phase
half life of 37 minutes and a slow phase half-life of 6.2 hours. This allows
onset of analgesia using CR oxycodone within one hour of ingestion
and analgesic duration of 12 hours.27
Oxycodone demonstrates unequal incomplete cross-tolerance when
switching to or from morphine.87, level III This is attributable to the
combination of kappa opioid receptor binding and mu receptor binding
by oxycodone or its metabolite.
Recommendation
Oral morphine should be the first line therapy for moderate to severe
cancer pain. (Grade C)
Oxycodone and fentanyl are alternatives to morphine for moderate
to severe cancer pain. (Grade C)
Transdermal fentanyl should only be considered for use when opioid
requirements are stable. (Grade C)
16
Pethidine
Nalbuphine
Methadone
17
19
Common indications for opioid switching:99, level II-3; 101, level III; 102 - 103,
21
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22
Example 1:
Conversion of oral morphine to oral oxycodone
Oral morphine mg/day (20 mg 4-hourly = 120 mg per day)
Conversion factor = divide by 1.5
Equivalent dose of oxycodone = 120 1.5 = 80 mg per day
Reduce equivalent dose by 25% = 60 mg per day (due to
incomplete cross-tolerance)
Therefore dose of SR oxycodone = 30 mg twice daily
Example 2:
Conversion of SC morphine to transdermal fentanyl
SC morphine mg/day (10 mg 4-hourly = 60 mg per day)
Conversion factor = divide by 1.2
Equivalent dose of transdermal fentanyl = 60 1.2 = 50 mcg
per hour
No dose reduction required (incomplete cross tolerance is
already taken into account in the conversion ratio)
Therefore dose of transdermal fentanyl = 50 mcg per hour
patch
Additional conversion:
Morphine 40 mg/day PO = Tramadol 200 mg/day PO
Source: Adapted with permission from Sacred Heart Hospice, Sydney New South Wales,
Australia
4.6
Constipation
Constipation is the most common side effect of opioid therapy.110, level III
It is recommended that all patients on regular opioid therapy should
23
b.
Sedation
Respiratory depression
24
rapidly titrated for relief of acute severe pain in cancer patients (Refer
to the Algorithm for Titration of Morphine for Rapid Pain Relief in
Adults).
Monitoring respiratory rate alone may be insufficient to detect respiratory
depression from opioid overdose. In a review of opioid-related adverse
events in cancer patients, Vila H Jr et. al. found that in 29 patients who
required management for opioid overdose, 27 (94%) had decrease in
their level of consciousness while only three (10%) had low respiratory
rates (<12/min).111, level II-3 Sedation almost always precedes respiratory
depression and therefore the assessment of sedation is a better early
clinical indicator of opioid-induced respiratory depression.112, level II-3
If severe respiratory depression occurs (respiratory rate <8/minute),
very low doses of naloxone (0.04 mg/40 mcg) titrated every 1 - 3
minutes against the patients respiratory rate can be used. Large bolus
doses of naloxone should not be given as it reverses the analgesic
effect and may precipitate opioid withdrawal.40; 81, level III
(Refer to Appendix 9 for Guide for Naloxone Use)
f.
Recommendation
Opioid-induced side effects should be anticipated and treated
adequately to ensure continuous effective opioid therapy. (Grade B)
Patients on regular opioid therapy should receive concurrent
prophylaxis for constipation using combination of stimulants and
softening laxatives. (Grade B)
4.7
Recommendation
In patients with renal and/or liver impairment, all opioids should be
used with caution and at reduced doses and/or frequency. (Grade
C)
4.8
TOLERANCE TO OPIOIDS
opioid doses are very high (oral morphine >600 mg/day, oral oxycodone
> 400 mg/day or transdermal fentanyl >200 mcg/hour), patients should
be referred to Pain Specialist or Palliative Medicine Specialist.
Clinicians should not delay initiation or escalation of opioid therapy
because of fear of opioid tolerance.
4.9
ADJUVANT DRUGS
Examples
Antidepressants
Amitriptyline
Duloxetine
Neuropathic pain
Anticonvulsants
Carbamazepine
Sodium Valproate
Gabapentin
Pregabalin
Neuropathic pain
N-Methyl-D-Aspartate
(NMDA) Receptor
Antagonists
Ketamine
Opioid-poorly
responsive pain
Bisphosphonates
Pamidronate
Zoledronate
Clodronate
Corticosteroids
Dexamethasone
Prednisolone
Anticholinergic
Hyoscine butylbromide
4.9.1 Antidepressants
Antidepressants are effective in the treatment of neuropathic pain. The
best evidence was for Tricyclic Antidepressants (TCAs). In a systematic
review of 31 RCTs, TCAs were effective in reducing neuropathic pain
with NNT=4 (95% CI 3 to 5).119, level I There was no significant difference
in overall effectiveness amongst all TCAs, RR=1.1 (95% CI 0.9 to 1.3).
Amitriptyline had the largest number of RCTs and the largest number of
patients investigating the role of TCAs for neuropathic pain with NNT=4
(95% CI 3 to 5).
The role of TCAs in neuropathic pain may be limited due to their adverse
effects where 20% of patients in the systematic review withdrew
because of intolerable adverse effects.119, level I For amitriptyline, the
NNH for major adverse effects=28 (95% CI 18 to 69) and NNH for minor
adverse effects=6 (95% CI 5 to 11).
There was insufficient evidence to recommend SSRIs for neuropathic
pain.119, level I However, SNRIs was effective in managing neuropathic
pain with NNT for venlafaxine=4 (95% CI 3 to 6) and duloxetine=5 (95%
CI 3 to 7).119 - 120, level I
4.9.2 Anticonvulsants
Anticonvulsants are effective in the management of neuropathic pain.
In two separate systematic reviews involving carbamazepine and
gabapentin, the NNT was 2 (95% CI 2 to 3)121, level I and 5 (95% CI 4 to 6)
respectively.122, level I In the systematic review on gabapentin, only one
study involved the role of gabapentin in cancer-related neuropathic pain
where it was found to be effective (p=0.025).121, level I The NNH for minor
harm for carbamazepine=4 (95% CI 3 to 8) and for gabapentin=4 (95%
CI 3 to 6) while NNH for major harm were not statistically significant for
both.
There was no significant difference in the overall effectiveness of
antidepressants compared to anticonvulsants, RR=1.3 (95% CI 0.9 to
1.8).119, level I
Pregabalin was effective in reducing central neuropathic pain associated
with spinal cord injury (p<0.001)123, level I and for diabetic peripheral
neuropathic pain (NNT=5, 95% CI 4 to 8).120, level I
4.9.3 Ketamine
Ketamine, an NMDA-receptor antagonist used for general anaesthesia
and sedation, can also be used in selected patients whose pain
28
29
Recommendations
Neuropathic cancer pain may be treated with antidepressants and/or
anticonvulsants, and the dose should be titrated according to the
clinical response and side effects. (Grade B)
Ketamine may be considered in patients with poorly controlled
cancer pain despite optimal opioid therapy. (Grade B)
Corticosteroids may be useful in symptom control in patients with
advanced cancer. (Grade C)
4.10 BISPHOSPHONATES
Bisphosphonates are structural analogues of pyrophosphonates, which
are natural components of bone crystal deposition. They are commonly
used in hypercalcaemia of malignancy, bone metastasis (with or without
hypercalcaemia), and have been found to result in pain relief in some
cases. The mechanisms of pain relieving effect of bisphosphonates are
poorly understood.
Two meta-analyses found significant pain relief with the use of
bisphosphonates (OR= 2.37, 95% CI 1.61 to 3.5 and NNT=6, 95% CI
5 to 11), with best response seen within 12 weeks.133 - 134, level I However
there is insufficient evidence to recommend bisphosphonates as first
line therapy for immediate effect.
Evidence suggests that bisphosphonates should be considered where
analgesics and/or radiotherapy are inadequate for the management of
painful bone metastases. No particular drug regimen was found to be
superior to another and the effect was not limited to any specific cancer
pathology.133 - 134, level I
Adverse drug reactions are generally mild, with nausea and vomiting
being the most common. NNH for adverse drug reactions requiring
discontinuation of therapy was 16 (95% CI 12 to 27).133, level I An
increased incidence of osteonecrosis of the jaw (ONJ) has been
associated with the use of bisphosphonates. Some epidemiological
studies had reported the incidence of ONJ to be 0.1 - 1.8% while in
others the incidence was much higher at 5 - 10%.135, level III Higher doses
have also been associated with renal impairment.136, level I
The circumstances under which bisphosphonates should be used
still remain unclear. Factors include the severity of pain and whether
the disease is widespread or localized. The delayed analgesic effects
(benefit at 12 weeks) and serious adverse effects including ONJ and
renal impairment should also be considered.
Monitoring of renal function and calcium levels should be carried out
routinely.
30
Since these agents can be taken for months or years, they can have
a significant financial impact. Health economic studies suggest that
treating patients with bisphosphonates may result in cost savings by
reducing skeletal related events (SREs).137 - 138, level III However, due to
the high cost of the drugs themselves, the cost-effectiveness ratios for
bisphosphonates are not favourable. Furthermore, the cost escalates
due to prolonged usage of bisphosphonates as patients live longer with
advances in cancer therapy.
(Refer to Appendix 7 for Suggested Medication Dosages and Side
Effects)
Recommendation
Bisphosphonates may be considered where analgesics and/or
radiotherapy are inadequate for the management of painful bone
metastases. (Grade A)
31
5.
ANTICANCER THERAPY
5.1
RADIOTHERAPY
This was well tolerated with 12% grade 3 - 4 toxicity which was mainly
haematological in nature.
Apart from painful bone metastasis, radiotherapy is also effective in
reducing pain related to advanced malignancies including:144 - 146, level II-3,
147, level I, 148 - 149, level II-3
33
34
6.
NON-PHARMACOLOGICAL/NON-INVASIVE TREATMENT
6.1
PSYCHOSOCIAL INTERVENTION
Exercise
and passive (p=0.029) joint range of motion.157, level I However, this trial
focused only on upper extremity pain and dysfunction in head and neck
cancer survivors.
b.
Acupuncture
36
7.
INTERVENTIONAL TECHNIQUES
VERTEBROPLASTY
39
8.
ASSESSMENT
TREATMENT
42
9.
9.1
43
EDUCATIONAL STRATEGIES
10.
FOLLOW-UP
Follow-up of patients with cancer pain may take place at home, primary
care clinics or specialised outpatient clinics including palliative care and
cancer pain clinics.
In addition to the various roles and care provided by health care
professionals and family caregivers in the follow-up of cancer patients,
social workers may assist by assessing and assisting patients to change
their attitude if this is a problem. Social workers can also help these
patients develop skills such as problem solving, better communication
and advocacy which will assist them in either the home or the ambulatory
care setting.195, level III
10.1 HOME CARE
A home care system with physicians skilled in palliative care using
WHO guidelines enables patients to receive pain treatment in the
comfort of their own homes and significantly improves pain intensity
(p<0.05).66, level II-3
Some of the challenges in putting pain management regimes into
practice at home include:196, level III
Obtaining prescribed medications
Accessing information
Managing side effects
Coping with and understanding complex information
Managing new unusual pain
Managing multiple symptoms simultaneously
In addition, caregivers at home had significantly higher levels of concern
in fatalistic beliefs (p=0.008) and addiction (p=0.006) compared to
caregivers in skilled care facilities.191, level III Caregivers reservations
or misinformation regarding pain management or administration
of medication can affect patients care, more so when it is not
addressed.33, level III Despite the above issues, a study showed palliative
care at home had a positive effect on pain intensity (p<0.0001).197, level III
10.2 AMBULATORY CARE
Family physicians play an important role in cancer care, including
informing the patient of the diagnosis, helping with treatment decisionmaking, providing psychological support and treating intercurrent
illness.198, level III They also recognise and manage complications of
cancer and cancer therapies which includes providing appropriate pain
management.
45
46
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do better? J Pain Symptom Manage 2003 Aug;26(2):716-22
193. Bennett MI, Bagnall AM, Jos Closs S. How effective are patient-based educational
interventions in the management of cancer pain? Systematic review and meta-analysis.
Pain, 2009 Jun;143(3):192-9
194. Yates P, Edwards H, Nash R, et. al. A randomized controlled trial of a nurse-administered
educational intervention for improving cancer pain management in ambulatory settings.
Patient Educ Couns, 2004 May;53(2):227-37
195. Glajchen M, Blum D, Calder K. Cancer pain management and the role of social work:
barriers and interventions. Health Soc Work, 1995 Aug;20(3):200-6
196. Schumacher KL, Koresawa S, West C, et. al. Putting cancer pain management regimens
into practice at home. J Pain Symptom Manage, 2002 May;23(5):369-82
197. Dumitrescu L, van den Heuvel-Olaroiu M, van den Heuvel W. Changes in symptoms and
pain intensity of cancer patients after enrolment in palliative care at home. J Pain Symptom
Manage, 2007 Nov;34(5):488-96
198. Smith GF, Toonen TR. Primary care of the patient with cancer. Am Fam Physician, 2007
Apr 15;75(8):1207-14
199. Meier DE, Beresford L. Outpatient clinics are a new frontier for palliative care. J Palliat Med,
2008 Jul;11(6):823-8
200. Williams JE, Chandler A, Ranwala R, et. al. Establishing a Cancer Pain Clinic in a
Developing Country: Effect of a Collaborative Link Project with a U.K. Cancer Pain Center.
J Pain Symptom Manage, 2001 Oct;22(4):872-8
201. Strasser F, Sweeney C, Willey J, et. al. Impact of a half-day multidisciplinary symptom
control and palliative care outpatient clinic in a comprehensive cancer center on
recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive
study. J Pain Symptom Manage, 2004 Jun;27(6):481-91
56
Appendix 1
SEARCH TERMS
The following MeSH terms or free text terms were used either singly or
in combination:
Neoplasms[Mesh],
tumors,
cancers,
Pain[Mesh],
Prevalence[Mesh], Signs & symptoms[Mesh], Syndrome[Mesh],
Diagnosis[Mesh], presentation, physical assessment, Pain
Measurement[Mesh], pain scale, reliability, validity, psychological,
psychosocial, assessment, cognitively impaired, psychological
distress, distress, Emotions[Mesh] Nursing[Mesh], prime
assessor,
Palliative Care[Mesh],
supportive care, cancer
pain management, Patient-Centered Care[Mesh], Patient
Care[Mesh], Family[Mesh], Patient Care Team[Mesh], Patient
Care Management[Mesh], Primary Health Care[Mesh], Physicians,
Family[Mesh]), interdisciplinary, Education[Mesh],
outcome,
barrier, Health Services[Mesh], principle, Organization and
Administration[Mesh], World Health Organization[Mesh], Guideline
[Publication Type], cancer pain ladder, Drug Therapy[Mesh],
Analgesics, Opioid[Mesh], administration and dosage[Subheading],
titration, breakthrough pain, Drug Tolerance[Mesh], Adjuvants,
Pharmaceutic[Mesh],
adjuvant
analgesics,
pregabalin
[Substance Name], Ketamine[Mesh], Dexamethasone[Mesh],
corticosteroid, opioid rotation, opioid switching, alternative opioid,
Diphosphonates[Mesh], bisphosphonate, Sedation score, Morphine
protocol, Radiotherapy[Mesh], Soft Tissue Neoplasms[Mesh],
Behavior Therapy[Mesh], Cognitive Therapy[Mesh],
Physical
Therapy Modalities[Mesh], Acupuncture[Mesh], Massage[Mesh],
Exercise[Mesh], Exercise[Mesh], Nerve Block[Mesh], Injections,
Spinal[Mesh], intrathecal therapy, Vertebroplasty[Mesh], followup, Physicians Role [Mesh], community care, home program*,
general practitioner, hospice, pain clinic, Outpatients[Mesh],
Outpatient Clinics, Hospital[Mesh], Ambulatory Care[Mesh],
57
Appendix 2
CLINICAL QUESTIONS
1.
2.
3.
What are the methods used for clinical assessment of cancer pain
and what is their reliability and validity?
4.
5.
6.
7.
8.
9.
10. What are the appropriate drugs and their efficacy for different types
of cancer pain?
11. What are the side effects and toxicity of these drugs and their
management?
12. What are the prescribing, titration and maintenance issues of
morphine and other strong opioids?
13. What are the clinical issues related to tolerance to opioids?
14. What are the pharmacological strategies for breakthrough pain and
other acute pain crises?
58
59
Appendix 3
SEDATION SCORE
Score
Sedation level
Clinical findings
None
Mild
Moderate
Severe
Source: Macintyre PE & Schug SA. Acute Pain Management: A Practical Guide. Saunders
Elsevier: London; 2007
Appendix 4
VARIOUS SCHEMES FOR CLASSIFYING CANCER PAIN
Aetiologic
classification
Pathophysiologic
classification
Location of cancer
pain syndromes
Temporal
classification
Acute
Breakthrough
Chronic
Severity-based
Mild
Moderate
Severe
60
Appendix 5
PAIN SCALES RECOMMENDED FOR USE IN ADULTS AND
PAEDIATRICS
1. For adult patients, use the combined Numerical Rating Scale/Visual
Analogue Scale (NRS/VAS)
2. For paediatric patients 1 month to 3 years old, use the FLACC Scale
3. For paediatric patients >3 - 7 old years, use the Wong-Baker Faces
Scale
4. For paediatric patients >7 years old, use the combined NRS/VAS
Scale (same as for adults)
Note:
i. All scales are scored from 0 (zero) to 10 (ten)
ii. Always use the same scale for the same patient
Descriptions of Pain Scales Used
1.
Sakit Kuat
2
10
The patient is asked rate his/her pain on a numerical scale where zero
(0) is no pain and ten (10) is the worst pain imaginable. In order to
assist the patient, he/she can is asked to slide the indicator along the
scale to show the severity of his/her pain.
2.
No hurt
61
Hurts worst
3.
FLACC Scale
Rating scale to be used for children less than 3 years of age or other
patients who cannot self-report. Can also be used in cognitively impaired
or demented adults.
Category
Scoring
0
No particular
expression or smile
1
Occasional grimace
or frown, withdrawn,
disinterested
2
Frequent to constant
quivering chin,
clenched jaw
Legs
Normal position or
relaxed
Uneasy, restless,
tense
Kicking or legs
drawn up
Activity
Squirming, shifting
back and forth, tense
Arched, rigid or
jerking
Cry
No cry (awake or
asleep)
Moans or whimpers;
occasional complaint
Crying steadily,
screams or sobs,
frequent complaints
Consolability
Content, relaxed
Reassured by
occasional touching,
hugging or being
talked to distractable
Difficult to console
Face
Each of the five categories (F) face, (L) legs, (A) activity, (C) cry and (C)
consolability is scored from 0 - 2, resulting in total range of 0 - 10
Source:
th
i.
Ministry of Health Malaysia. PAIN as the 5 Vital Sign Guidelines for DOCTORS Management
of Adult Patients. Putrajaya: MOH; 2008
ii.
iii.
Ministry of Health Malaysia. PAIN as the 5 Vital Sign Guidelines for NURSES Management
of Peadiatrics Patients. Putrajaya: MOH; 2008
th
62
th
Appendix 6
DISTRESS THERMOMETER SCREENING TOOL
Source:
Reproduced with permission from The NCCN 1.2010 Distress Management Clinical Practice
Guidelines in Oncology. National Comprehensive Cancer Network, 2010. Available at: http://
www.nccn.org. Accessed [January 6, 2010] To view the most recent and complete version of the
guideline, go online to www.nccn.org
63
64
Ibuprofen
Mefenemic Acid
Diclofenac
Sodium
Non-Selective
NSAIDs
Meloxicam
Diclofenac
Potassium
Paracetamol
Simple analgesic
Peptic ulcer
GI bleed
Platelet dysfunction
Renal failure
Hypertension
Allergic reaction in
susceptible
individuals
Increase in CVS
events
Rare
Gastroduodenal ulcer
Asthma
Bleeding disorder
Renal dysfunction
Ischaemic heart
disease
Cerebrovascular
disease
Inflammatory bowel
disease
Hepatic impairment,
alcohol dependence
Physicians and
patients should weigh
the benefits and risks
of NSAID/coxib
therapy.
Preferred drug
particularly in elderly
patients.
Liver damage following
over dosage.
Current data suggest
that increased CV risk
may be an effect of the
NSAID/coxib class.
Appendix 7
Weak opioids
Selective Cox-2
Inhibitors
60 - 90 mg daily
120 mg daily in acute pain
Max: 90 /day
Long term use should be
limited to a maximum of
90 mg daily. 120 mg
daily may be used for
acute pain relief but for
short term only.
50 - 100 mg, 6 - 8-hourly
Max: 400 mg/day
30 - 60 mg, 6 - 8-hourly
Max: 240 mg/day
Etoricoxib
Dihydrocodeine
tartrate
(DF118)
Tramadol
Celecoxib
65
Nausea
Vomiting
Constipation
Drowsiness
Dizziness
Nausea
Vomiting
Constipation
Drowsiness
Hypertension
Renal impairment
Increase in CVS
events
Renal impairment
Allergic reaction in
susceptible
individuals
Increase in CVS
events
In elderly, start at
lowest dose (50 mg)
and maximum of 300
mg daily
Respiratory
depression
Acute alcoholism
Paralytic ileus
Raised intracranial
pressure
Risk of seizures in
patients with history of
seizures and with high
doses
Ischaemic heart
disease
Cerebrovascular
disease
Contraindicated in
hypersensitivity to
sulfonamides
Uncontrolled
hypertension
Ischaemic heart
disease
Cerebrovascular
disease
Associated with a
lower risk of serious
upper gastrointestinal
side effects
Antidepressant
Strong opioids
Combinations of
opioids and
paracetamol
66
Amitriptyline
Oxycodone
Transdermal
fentanyl
Equianalgesic dose of
total 24 hours opioid
requirement
(refer Conversion Table
(Table 3)
Starting dose (oral):
5 mg of IR 4 - 6-hourly
CR oxycodone: to be given
12-hourly dosing
Start with 10 - 25 mg
nocte.
Increase weekly by 25
mg/day to a max of 150
mg/day
Anticholinergic
effects e.g. dry
mouth, drowsiness,
urinary retention,
arrhythmias
Not common in
cancer pain:
Sweating
Euphoria
Respiratory
depression
Pruritus
Myoclonus
Common:
Nausea
Vomiting
Drowsiness
Constipation
Sedation
SR oral morphine: to be
given in 12-hourly dosing
Nausea
Vomiting
Drowsiness
1 - 2 tablets, 6 - 8-hourly
Max: 8 tablets/day
Paracetamol 325
mg + tramadol
37.5 mg
(Ultracet)
Morphine
Constipation
1 - 2 tablets, 6 - 8-hourly
Max: 8 tablets/day
Paracetamol 500
mg + codeine 8
mg
(Panadeine)
Not recommended in
elderly patients with
cardiac disease,
glaucoma, renal
disease
Acute bronchial
asthma
Respiratory
depression
Hepatic impairment
Renal impairment
Alcohol dependence
Epilepsy
Interaction with
tramadol
Nortriptyline may be a
suitable alternative
and better tolerated in
elderly at similar doses.
Transdermal
fentanyl Not to be used unless
opioid dose is stable.
Minimum dose: 12
mcg/hr=30 mg oral
morphine in 24 hrs
Not to be used in
opioid naive patients
Decrease in side
effect profile of
tramadol and
paracetamol while
maintaining efficacy
Anticonvulsants
Pregabalin
Carbamazepine
Gabapentin
30 - 60 mg/day
Max: 120 mg/day
Duloxetine
Drowsiness,
dizziness
GI symptoms
Mild peripheral
oedema
Dizziness
Allergic reaction
Ataxia
Fatigue
Leucopenia
Nausea
Vomiting
Drowsiness
Gastrointestinal
disorder
Excessive sweating
CNS disorder
Dose adjustment
needed in renal
impairment
Narrow-angle
glaucoma
Potent CYP1A2
inhibitors
Concomitant use of
MAOIs
Hypertension
Increased ocular
pressure
Latent psychosis
Confusion
Agitation
Well tolerated.
Serious adverse
events are rare.
Interaction with
tramadol
67
68
69
1 - 2 sachets/day
Macrogol
10 - 20 mg, 6 - 8-hourly
2 - 4 tablets daily in
divided dose
Senna
Metoclopramide
5 - 10 mg orally, 1 - 2
times daily
Max: 30 mg/day
Bisacodyl
Antiemetics
15 - 45 ml orally, 6 - 8hourly
Lactulose
Laxatives
Oral/ IV/SC: 8 - 16 mg
daily or divided doses
(initial dose), then to
reduce to lowest possible
dose (usually 2 mg/day)
Dexamethasone
Corticosteroid
Extrapyramidal
reactions
Dizziness
Drowsiness
Diarrhoea
Nausea
Vomiting
Rectal irritation
Stomach cramps
Bloating
Abdominal distension
Nausea
Diarrhoea
Increased or
decreased appetite
Insomnia
Indigestion
Nervousness
Myopathy
Oral candidiasis
Adrenal suppression
Bloating
Epigastric pain
Flatulence
Nausea
Vomiting
Cramping
Atony of colon
Epileptic patients
Gastrointestinal
hemorrhage
Severe inflammatory
bowel disease
Fructose intolerance
Appendicitis
Intestinal obstruction
Gastroenteritis
Allergies especially to
tartrazine
Hypersensitivity to
lactulose products
Galactosemia
Patients requiring
galactose free diet
Reasonable fluid
intake is required for
efficacy
Should be given
before 6 pm to reduce
risk of insomnia.
70
th
Headache
Sensation of flushing
or warmth in the
head and
epigastrium
Constipation
Extrapyramidal
symptoms
Dry mouth
Extrapyramidal
symptoms
Dystonia
Prolonged QT
interval
Neuroleptic
malignant syndrome
Constipation
i. Sunthornsaj N, Fun LW, Evangelista LF et. Al (Ed). MIMS.com. 117 Edition 2009. Hong Kong; CMPMedica: 2009
ii. Thomson Reuters. Micromedex 1.0 (Healthcare Series). Greenwood Village Thomson Reuters; 2009
st
iii. Malaysian Association for the Study of Pain. The Malaysian Low Back Pain Management Guidelines 1 Edition. 2009
Source:
8 mg, 12-hourly
Ondansetron
10 - 30 mg daily in divided
doses
1 mg, 12-hourly
Granisetron
Prochlorperazine
Haloperidol
Appendix 8
GUIDE FOR TRANSDERMAL FENTANYL USE
Important notes when using transdermal fentanyl:
When indicated, transdermal (TD) fentanyl should only be used in
patients already on stable doses of morphine or other opioids.
TD fentanyl is contraindicated in patients with severe uncontrolled
pain where rapid dose titration is required.
When converting to TD fentanyl from 4-hourly morphine, overlap
regular 4-hourly morphine for the first 12 hours after applying the
patch.
When converting to TD fentanyl from 12-hourly SR morphine or CR
oxycodone, apply the patch and serve the final dose of SR morphine
or CR oxycodone at the same time.
When converting to TD fentanyl from continuous SC/IV infusion of
morphine or fentanyl, continue the infusion for 12 hours after applying
the patch.
71
Appendix 9
GUIDE FOR NALOXONE USE
Naloxone for iatrogenic opioid overdose: Seldom necessary in palliative care setting
Used only if life threatening overdose occurs
NOT USED for treating drowsiness or delirium associated with
opioids which is not life threatening
IV route is preferable but SC or intramuscular can also be used
Onset of action: 1 - 2 minutes via IV and 2 - 5 minutes via SC
Half-life: about one hour
If opioid overdose is confirmed: Respiratory rate >8/minute and arousable Wait and see after
withholding opioids
Respiratory rate <8/minute and comatose or cyanosed Treat with
naloxone
o Dilute 400 mcg (1 ampoule) in 10 ml water
o Administer small boluses of 0.5 ml (20 mcg) every two minutes
until respiratory rate is satisfactory
o Titrate dose against respiratory rate and NOT conscious level as
this may result in return of severe pain or physical withdrawal
May need further boluses after one hour and sometimes infusion in
cases where overdose is associated with long acting opioids (SR
tablets, transdermal fentanyl or methadone)
72
Appendix 10
PAIN MANAGEMENT
PROVIDERS
AND
PALLIATIVE
CARE
SERVICE
PAIN CLINICS
Hospital
Tel No.
URL
603-61203233
http://www.hselayang.moh.gov.my
606-2822344
http://www.hmelaka.moh.gov.my
607-3565000
http://www.hsi.moh.gov.my
605-2533333
http://www.hipoh.moh.gov.my
609-7452000
http://www.hrpz2.moh.gov.my
603-33757000
http://www.htar.moh.gov.my
603-79494422
http://www.ummc.edu.my
603-91455555
http://www.ppukm.ukm.my
609-7663000
http://www.medic.usm.my
Tel No.
URL
603-61203233
http://www.hselayang.moh.gov.my
60-45383333
http://www.hospbm.moh.gov.my
6089-212111
http://www.hdok.moh.gov.my
606-2707653
http://www.hmelaka.moh.gov.my
604-2293333
http://www.hpp.moh.gov.my
6088-206258
http://www.qeh.moh.gov.my
605-5222245
http://www.hipoh.moh.gov.my
609-7485533
http://www.hrpz2.moh.gov.my
607-2231666
http://www.hsajb.moh.gov.my
60-47303333
http://www.hsbas.moh.gov.my
609-6233333
http://www.hsnzkt.moh.gov.my
6089-773533
http://www.htwu.moh.gov.my/
609-5133333
http://www.htaa.moh.gov.my
606-7623333
http://www.htjs.moh.gov.my
6082-208069
http://www.hus.moh.gov.my
603-79494422
http://www.ummc.edu.my
603-91455555
http://www.ppukm.ukm.my
73
Tel No.
URL/E-mail
Hospis Malaysia
603-91333936
http://www.hospismalaysia.org
info@hospismalaysia.org
604-2284140
http://www.malaysianhospicecouncil.org
ncsmpg@gmail.com
Charis Hospice
604-8266757
http://www.charishospice.com
charisp@streamyx.com
6088-222315
http://www.sabah.org.my/scss/cancer
cancer_sabah@yahoo.com
Hospice Klang
603-33242125
http://www.hospiceklang.org
hpsklang@gmail.com
Hospice Malacca
606-2925849
drrajagopal@hotmail.com
Hospice Pahang
609 5670743
Kasih Hospice
603-79607424
http://www.kasih-hospice.org
admin@kasih-hospice.org
6082-337689
cancercare@pd.jaring.my
607-2228858
pcajb.admin@gmail.com
6088-231505
http://www.sabah.org.my/pcakks
paliatif@streamyx.com
604-2284140
http://www.penanghospice.org.my
chanke@islandhospital.com
605-5464732
ppcs95@tm.net.my
604-7332775
sriwahyu2006@yahoo.com.my
609-7475418
drimisairi@kit.moh.gov.my
6089-774666
vicraja@gmail.com
609-8593333
drahmah@trg.moh.gov.my
606-7621216
hospiceseremban_2008@yahoo.com
604-2295481
plotus@streamyx.com
604-2284140
http://www.penanghospice.org.my
ncsmpg@gmail.com
6082-276575
tangtiengswee@gmail.com
605-8072457
veraliew@hotmail.com
6089-632219
http://www.hospicesdk.com
hcs98@hospicesdk.com
Source:
i. Malaysian Association For the Study of Pain, 2010 (internet communication, 6 February 2010 at
http://masp.org.my)
ii. Hospis Malaysia, 2010 (internet communication, 6 February 2010 at http://www.hospismalaysia.
org/index.php?mid=385)
iii. Asia Pacific Hospice Palliative Care Network, 2010 (internet communication, 6 February 2010
at http://www.aphn.org)
74
LIST OF ABBREVIATIONS
75
INDICATORS
FOR
QUALITY
ACKNOWLEDGEMENT
The members of the development group of these guidelines would
like to express their gratitude and appreciation to the following for their
contributions:
Panel of external reviewers who reviewed the draft
Dr. Sheamini Sivasampu, Public Health Physician
Ms. Loong Ah Moi, Nursing Sister
Technical Advisory Committee for CPG for their valuable input and
feedback
All those who have contributed directly or indirectly to the development
of the CPG
DISCLOSURE STATEMENT
The panel members had completed disclosure forms. None held shares
in pharmaceutical firms or acted as consultants to such firms. (Details
are available upon request from the CPG Secretariat)
SOURCES OF FUNDING
The development of the CPG on Management of Cancer Pain was
supported financially in its entirety by the Ministry of Health Malaysia
while the printing was partly funded by Malaysian Association for the
Study of Pain (MASP).
76